Better Sex Through Mindfulness: How Women Can Cultivate Desire

By Lori A. Brotto, PhD and Emily Nagoski

• According to a landmark study published in the Journal of the American Medical Association,  43 percent of women experience “sexual dysfunction." at some point in their lives



• Brotto is a sought after commentator on sexuality and sexual health



• Mindfulness, an ancient Buddhist practice, is becoming mainstream. In 2012 8% of the US population practiced it in some form. (18 million people)



• Google searches for both mindfulness and meditation have increased in the last 5 years. There are almost 5 million Instagram posts with the hash tag #mindfulness 



• Addresses things medication cannot – when the body responds, but the mind is preoccupied



• No need for any previous experience with meditation. Includes exercises anyone can do at home.

• Language: English
• Publisher: Greystone Books
• Release date: Apr 21, 2018
• ISBN: 9781771642439

Book preview

INTRODUCTION

ALTHOUGH PREVAILING SOCIETAL beliefs would suggest that sexual response is automatic, pleasurable, and universally desired, the reality is that female sexual dysfunction is extremely common around the world, with between 15 and 31 percent of women experiencing lasting and distressing sexual complaints. Female sexual dysfunction can affect one or more domains of sexuality (sexual desire, arousal, orgasm, and sexual pain), is associated with distress, and may interfere with other aspects of life. Among the different expressions of sexual difficulty, low desire—or loss of libido—is the most common, affecting up to half of women at some point in their lives.

The causes of sexual dysfunction in women are multifaceted and often unclear. In many women, the issues that contribute to ongoing sexual concerns may be quite different from the factors that originally provoked them. For example, the use of a medication that directly interferes with sexual response (such as an antidepressant) may have triggered the start of the difficulty, and then, over time, the woman’s anxiety about whether or not she will respond sexually in the way she wants to may contribute to keeping the sexual dysfunction going. It is clear that sexual difficulties are associated with poor physical, emotional, and relationship well-being and are a major burden for many women.

My goal in writing this book is to bring the issue of low sexual desire in women into the open so that women feel less shame and are empowered to cultivate their feelings of sexual desire. In my own research to investigate effective treatments for women, I have focused on mindfulness meditation, an ancient Buddhist practice with a four-thousand-year history that involves paying attention compassionately and without judgment. I have been studying mindfulness as a potential treatment for sexual dysfunction in women since 2002, and over the years, many women, sex therapists, and physicians have asked me where they can learn more about this life-changing skill. This book is a response to those many requests, and I hope that the research findings you will learn about here inspire you to make mindfulness a part of your life. I have included many of the exercises that the women participating in our research* have taken part in, in the hope that you can make them a regular part of your daily life. The ideas and suggestions throughout this book are based not on any one individual’s personal experience but rather on the feedback (formal and informal) from hundreds and perhaps thousands of women who found paying attention to be key for unlocking their sexual drive.

1999—A LANDMARK YEAR

THE YEAR 1999 was one of notable events in the field of sexuality. That was the year Viagra was approved for the treatment of erectile dysfunction in Canada (it had already been approved in the United States in 1998), and the colossal ensuing media coverage led several experts to ask: What about women? Many speculated that it would be only a matter of time before Pfizer, the pharmaceutical company that owned Viagra, turned its attention to women. This seemed appropriate given that there were no approved medications for the treatment of sexual dysfunction in women, and Viagra was thought to be effective in women too.

That same year, I was searching for new research to embark upon as I began my doctorate degree in Clinical Psychology. After spending hundreds of hours over a half-dozen years in a small testing room injecting rats, operating on their organs (including their brains), exposing them to stress, watching their sexual behaviors, and ultimately euthanizing them, I was ready for a new population to study (and comfier testing quarters). Moreover, although the rat provided a useful model on which to test the effects of various experimental manipulations on sex, in the end, it provided only an incomplete picture of the higher-order cognitive processes, like emotion, thinking, and desire—all pivotal in the human experience of sex.

Also in 1999, a landmark study published in the Journal of the American Medical Association (JAMA) claimed that 43 percent of women and 31 percent of men experienced sexual dysfunction. That nearly half of women could meet the criteria for a sexual dysfunction suggested that either there was a real problem inhibiting women’s healthy sexual functioning or these rates of dysfunction were exaggerated. Nearly every major media outlet reiterated the JAMA paper’s findings about women’s sexual dysfunction, igniting anxiety among women that they might be suffering from FSD*—and inspiring sex scientists to probe deeper into just what was behind these high rates of sexual discontent in women.

Influenced by the 1999 publication and my feminist beliefs about the need for solid science aimed at understanding the sexual experiences of women, I launched a series of studies examining sexual arousal in women with and without sexual concerns. I invited women into a university laboratory and, using a tampon-shaped probe called a vaginal photoplethysmograph, which the women inserted into their vaginas, measured their physical sexual arousal responses to erotic films—totally in private.

The vaginal photoplethysmograph emits a beam of infrared light, and a sensor on the probe detects the amount of light scattered from the vaginal wall. The degree to which light is absorbed into the walls of the vagina reflects how much blood has congested in the area, which, in turn, provides an indirect measure of physical sexual arousal. (Of course, the amount of blood flow into the genital area may not relate to how aroused a woman says she is—a topic that will be explored more fully later.) Some of this research revealed differences between women with and without sexual difficulties when they were tested in this lab environment.

A notable influence on my research questions was the direct result of the hours I trained under Dr. Rosemary Basson, a physician and director at Vancouver’s BC Centre for Sexual Medicine and a luminary in the study of women’s sexuality. Basson listened intently to women’s stories of their loss of sexual desire and how they mourned the spontaneous sexual desire of their youth. As her patients spoke, Basson started to draw a circle on her notepad using the following words: incentives for sex → sexual triggers → sexual arousal first → responsive sexual desire emerges → sexual satisfaction → greater incentive for sex (which closed the circle). She formulated a circular sexual response cycle (discussed in more detail in Chapter 4), which encouraged women to identify the factors that could elicit sexual arousal for them by inviting them to think about why they had sex, and also what types of triggers made them aroused. Basson helped women to appreciate that their sexual desire did not need to be present before a sexual encounter but could be cultivated during sexual activity. She helped thousands of women to feel normal* and empowered. Her innovative thinking about the responsive nature of sexual desire was key in my work exploring mindfulness as one way of eliciting women’s sexual response and paying attention to it.

The years I spent with Basson, early in my career and in the decade since, convinced me that there was much variability in how women experienced and expressed their sexual desire and in the various triggers that could elicit a sexual response. Where women generally aligned was in their view that biomedical factors alone were rarely the underlying cause of their sexual complaints. Moreover, once they learned that sexual desire could be ignited, and that it often emerged after they started a sexual encounter and experienced sexual arousal, they were keen to learn new skills to cultivate sexual desire naturally. They seemed to be asking us to teach them ways to tune in.

MY INTRODUCTION TO MINDFULNESS

I FEEL ALIVE. . . fully connected . . . totally present. Nothing else in the world mattered. These were some of the phrases a sample of women from Seattle uttered when I interviewed them about their experiences of sexual desire. I was doing my postdoctoral fellowship with Dr. Julia Heiman at the University of Washington School of Medicine, and we wanted to know more about how women talked about sexual desire when they had it. The women told me stories about when, where, and how they felt sexual desire and opened a window onto their most private encounters. It is evident to me now—though it was not at the time—that these women were engaging mindfully during their pleasurable sexual encounters, and when they felt sexual desire, they were also fully in the moment—and certainly not thinking about to-do lists or whether they had run out of milk. Little did I realize that I was about to immerse myself in mindfulness training and that it would change everything I understood about sexual response in women.

I had begun an intensive therapy training program to learn dialectical behavior therapy (DBT),a skills-based treatment to address self-harm and suicidal behaviors. Patients in a DBT program receive a combination of individual weekly sessions with a therapist, in which they use problem solving to deal with the week’s crises, and participate in a weekly skills group where they are taught specific problem-solving skills in interpersonal effectiveness, tolerance of distress, regulation of emotions, and mindfulness. The mindfulness practice involves remaining in the present moment, fully experiencing each negative sensation and emotion, and resisting the tendency to both think about the future or ruminate about the past and also fend off any negative feelings. Patients are taught that they can tolerate the distressing negative emotions of the present moment if they can learn to remain with them, riding each wave of seemingly intolerable feelings—even suicidal ones.

The mindfulness practice intrigued me—and puzzled me—the most, and I thought about Amanda*—a woman I was treating who went home each night after work, locked herself in her bathroom, and used her husband’s razor blade to cut perfectly parallel lines in her wrist, an act that brought her relief as she watched the blood seep out. Cutting helped her deal with the intensely negative feelings she had toward her boss, her fear of losing her husband, and her belief that she had no close friends. Could teaching Amanda to pay attention to her negative thoughts, intense emotions, and impulse to cut her wrists actually reduce her nightly cutting ritual? I learned that teaching people like Amanda to pay attention to the present moment, to notice the details of the breath, and to ride out their in-the-moment urge to hurt themselves put them safely in the here-and-now. It was not the current moment that was unbearable to them; rather, it was future-oriented thoughts about having a life not worth living, a life of torment that would never come to an end, that made them feel hopeless and suicidal. There was safety and a sense of calm in the present moment, even if that included really intense negative feelings.

Observing suicidal clients surf their intense feelings with mindfulness and ground themselves in the present conveyed to me that mindfulness could be an effective way of putting people in touch with real sensations and shielding them from imagined or expected outcomes and scenarios. If all one had to do was pay attention, to tune in to the truth of present-moment bodily sensations and feelings, then it seemed to me that mindfulness was potentially a cure for the suffering experienced by so many people.

I had started reading about the emerging science of teaching meditation to patients with depression, anxiety, and chronic pain. New findings showed that mindfulness helped reduce stress and improve immune function in cancer survivors, and this translated into an improved quality of life. In my clinical practice, I was seeing gynecologic cancer survivors with sex-related problems. Many of these women had received surgical treatment to remove their infected organs (such as the cervix or uterus) or radiation therapy, which led to scar tissue and impairments in blood flow.

One day, a patient I will call Anya said to me, while fighting back tears, I don’t feel anything in my sexual parts. I want to have sex, but when we start, my body just doesn’t cooperate. My genitals feel dead. Anya was one of many cancer survivors who said they did not notice any vaginal lubrication and felt no sexual arousal in their body. No pulsing. No tingling. No electricity. And yet, when they came into the sexual psychophysiology laboratory at the University of Washington and we measured their vaginal blood flow response while they reclined and watched a series of short erotic films, the vaginal photoplethysmograph recorded a strong genital blood flow response.

How could a robust genital response be happening without women noticing it? How could it be so different from men’s experiences of having an erection, in which they invariably were aware of the erection and felt in the mood for sex? When men were tested in a similar lab setup (with a penile strain gauge—a rubber-band-like instrument placed over the flaccid penis that detects and measures an erection—instead of a vaginal probe), their erections tended to parallel how sexually aroused they reported feeling while watching porn. I wondered whether what we were observing in these women might be an example of the brain-body disconnect, where a physical response in the body is not registered in the person’s mind, leaving her totally unaware that the physical response is happening. Could women be taught to pay attention to their bodies during sexual stimulation, and would this increase the brain-body communication in a way that might trigger sexual desire? Could mindfulness be a way of enhancing that connection?

I immersed myself in learning about mindfulness. First, to understand the origins of mindfulness meditation, I read The Miracle of Mindfulness by Thich Nhat Hanh, a Buddhist monk. Then I read the books of Jon Kabat-Zinn, an American molecular biologist who is credited with introducing mindfulness to the Western world through its applications to people living with chronic pain. In Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness, Kabat-Zinn describes the early formation of mindfulness-based stress reduction (MBSR),which he taught to patients with intractable pain at the University of Massachusetts Medical Center.

There was so much richness in how Kabat-Zinn wrote about mindfulness for chronic pain and so much relevance to the women with cancer and sexual dysfunction that I was treating. As I thought about the stories women shared with me when I asked them how they knew they felt sexual desire, it became evident to me that feeling sexual desire corresponded with being mindful. Maybe sexual desire was not even possible unless one was mindful. Perhaps some of the mindfulness exercises found to benefit patients with suicidal tendencies and chronic pain might also benefit women who had lost their sexual sensations. It seemed to be a perfect hypothesis that we could test.

THE BEGINNINGS OF

MINDFULNESS-BASED SEX THERAPY

GYNECOLOGIC ONCOLOGISTS AT the Seattle Cancer Care Alliance often saw women in their post-treatment follow-up appointments who had these problems, but they had very few treatment options to offer and were keen to collaborate with us. Dr. Heiman at the University of Washington, two of my clinical psychology supervisors, and I therefore cobbled together the skeleton of a three-session mindfulness-based program for gynecologic cancer survivors with sexual arousal problems.

Within a month, the cancer doctors had referred twenty-five women who had been treated with radical hysterectomy for early-stage cervical cancer to my study. During my telephone calls with the women before enrolling them in our study, I consistently heard comments such as, My body has betrayed me—first by cancer, and now with a sexual dysfunction, accompanied by deep sadness and distress about the apparent loss. Most of the women I spoke with were young (under fifty) and not prepared to accept a sexless life. Although the prospect of losing their partners because of the sexual concerns brought on utter dread, many of them said they would understand if their partner left them for someone who still had the capacity to feel sexual. These women were motivated to take part in whatever treatment was available to them, even if it was something that had not yet been shown by science to work. Because what I had to offer them did not entail administering medications or hormones, they seemed open to participating in this experimental trial. Also, given the degree of their sex-related distress, many of them felt that they could not possibly be any worse off after this new experimental program.

The women came into my office, one by one, and we breathed together—slowly and with focus. I guided them to notice sensations in different parts of their body and to watch for the tendency for their minds to wander. The instructions were simple: pay attention, notice the dominant sensation and the smaller sensations that make up the dominant one, guide the mind back when it drifts, and so on. After completing this exercise with about two dozen women, we examined the women’s responses and found that our brief mindfulness-based program helped this group of cervical cancer survivors to experience a significant increase in their levels of sexual desire and arousal. To our delight, they also reported a statistically significant reduction in sex-related distress and depressive symptoms, an increase in sexual satisfaction, and improvements in overall mental well-being.

After the pilot study, we repeated the study at the University of British Columbia with a larger sample of cancer survivors. Half the women waited a few months before beginning the mindfulness program so that we could measure what happens to their sexual response simply as a function of waiting to get into treatment. Whereas levels of sexual desire and arousal did not change during the months that the women waited to begin the program, participating in the mindfulness program led to the same significant improvements in sexual response and desire that women taking part in the pilot study had shown. It seemed to us that mindfulness was responsible for these improvements and that simply waiting it out did not lead to any improvements in their libidos.

Over the next several years, our team of collaborators expanded to include key experts in sexual medicine and mindfulness meditation in Vancouver, BC. My own personal practice in mindfulness continued as I became part of a group of therapists who met monthly to deepen our own experience with meditation under the careful guidance of teachers. Our research team received funding from the Canadian Institutes of Health Research to examine mindfulness in a variety of different populations of women with sexual concerns as well as women with genital pain (discussed later in this book). The women participating in our program provided rich feedback, which strengthened our program, and their feedback shaped the treatment manuals that guided our exercises. Now, a dozen years later, mindfulness has been accepted as an important treatment option for women with sexual dysfunction, and experts around the world are seeking their own formal training in mindfulness in hopes of sharing these skills with their patients.

This book is intended for women of all ethnic backgrounds, cultures, ages, sociocultural positions, genders, bodies, orientations, and relationship statuses. Whether you are struggling with a sexual difficulty such as low libido or lack of orgasm or you simply want to enhance your sex life, I hope that the simple practice of paying attention, nonjudgmentally, moment by moment, will cultivate sexual desire and a new awareness of sexual arousal for you.

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* Research is typically a team effort, and while this book is based on my direct experience of evaluating mindfulness as a therapeutic approach, you’ll see that in places I refer to we or our when I’m talking about research, for example, that my team and I collaborated on.

* Although FSD , or female sexual dysfunction, is used regularly in the medical literature as referring to a particular condition, it is worth noting that FSD is an umbrella term that includes various sexual dysfunction diagnoses in women. As an imprecise diagnosis, it does not tell one whether the dysfunction pertains to motivation for sex, to the capacity for a physical sexual arousal response, or to pain with sex.

* I am fully aware that the term normal can elicit negative reactions as it may imply that there are only two categories: normal and abnormal. However, the use of normal in this case (and throughout this book) is intended to mean common, expected, and entirely within the range of human experiences. Women themselves often use the word normal when they feel validated and understood in their sexuality.

* All stories are based on actual patients, but names and details have been changed.

CHAPTER 1

SEX IN A

MULTITASKING WORLD

Ultimately, I see mindfulness as a love affair—with life,

with reality and imagination, with the beauty of your own being, with

your heart and body and mind, and with the world.

JON KABAT-ZINN, Mindfulness for Beginners: Reclaiming

the Present Moment—and Your Life

IN MOST RESPECTS, Shelina was a typical forty-eight-year-old married woman and mother of two. She had a thriving career as the lead realtor at her firm, her teenage children were well adjusted and confident, and she and her husband, Akmal, had a rich circle of friends and social activities. However, Shelina had a secret she could not share. Inside, she felt broken. The fire that she once felt when gazing at her partner was now a dull flicker. She longed for the physical cravings she used to experience for sex that had been replaced by an orchestrated plan and predictable outcome.

During her weekly sexual encounters, which were planned for Friday nights between 11:00 and 11:15 pm, she deliberately avoided the foreplay she used to enjoy. No more kissing, touching, or caressing. She would zone out while Akmal touched her—thinking about plans for the next day and engaging